小主动脉根部的主动脉瓣置换临床经验（英文）

小主动脉根部的主动脉瓣置换临床经验 Weng, Yuguo, MD, PhD, Roland Hetzer, MD, PhD Deutsches Herzzentrum Berlin Clinical Experience （毫米必争） Selection of the Prosthesis (ext. 2mm) Surgical Technique Implantation (ext. 1mm) Extended Aortoplasty (ext. 2mm) Konno-Rastan Aortoventriculoplasty (ext. 4mm) Apex Left Ventricle to des. Aorta Conduit Transcatheter Aortic Valve Replacement Selection of Prosthesis VALVE SIZE vs HEART VALVE DIAMETERS Nominal Valve size provides an indication either of the Valves Tissue Annulus Diameter (TAD) or Internal Orifice Diameter (IOD) Orifice to tissue annulus ratio (Geometric Orifice Area/Mounting Area) Intra-annularPartially Supra-annularTotally Supra-annular Sewing ring thickness Housing thickness Housing thicknessNo obstruction 60 - 65 %80 - 85 % 100 % Native Aortic Orifice Area Selection of Prosthesis Reduced Pressure Gradient Carbomedics Top Hat: new sizers Outer Diameter Internal Diameter Implantation Technique intra-annular vs. supra-annular Totally supra-annular valve: 100% orifice-to-annulus ratio.Totally supra-annular valve: 100% orifice-to-annulus ratio. Selection of Prosthesis Reduced Pressure Gradient Selection of Prosthesis Helpful for Double Valve Surgery Extended Aortoplasty (ext. 2mm) Valve Replacement in Small Aortic Root Manougian and Seybild-Epting J Thorac Cardiovasc Surg 1979;78:402-12 Types of Aortic Stenosis Valvular Subvalvular (muscular, fibrotic, mixed) Supravalvular Subvalvular Idiopathic Accessory mitral tissue Shone complex (aortic+mitral stenosis+coarctation) #3 Wire Moved To From Center To Side, Creating Central Opening for LVOT Visibility Carbomedics Top Hat: new sizers Subvalvular (muscular, fibrotic, mixed) Subvalvular (muscular, fibrotic, mixed) Subvalvular (muscular, fibrotic, mixed) Subvalvular Membranous Aortic Stenosis Angiography Subvalvular Left Ventricular Outflow Obstruction in AVSD 1993 IAVSD correction 1996 resection of LVOT obstruction 2005 reoperation for LVOT obstruction Pre OPPost OP Supravalvular Aortic Stenosis Williams-Beuren Syndrome Reduced intelligence Muscular and sceletal anomalies Dental malocclusion Elfin facies Infantile hypercalcinemia in 5% of pts Involement of pulmonary, renal arteries and aortic arch branches Williams et al. Circulation 1961; 24:1311-18 Beuren et al Circulation, 1962; 26:1235-40 Supravalvular Aortic Stenosis Coronary artery involvement in Williams-Beuren syndrome Supravalvular Aortic Stenosis Williams-Beuren Syndrome PA Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Surgical Options Simple patch enlargement Doty technique Brom three-patch technique Direct anastomosis (coarctation-type repair) Replacement of the ascending aorta Apico-aortic conduit Goal: restoring the aortic root geometry and relieving of obstruction Supravalvular Aortic Stenosis Doty Technique Doty et al. J Thorac Cardiovasc Surg 1977;74:362-71 RCA Donald B. Doty Supravalvular Aortic Stenosis Brom three-patch technique Modified Brom technique Brom 1988 Myers et al. J Thorac Cardiovasc Surg 1993;105:281-8 ? AB C D AB C D Gustav Brom Supravalvular Aortic Stenosis(n-17) Early and Long-Term Results Early mortality 0% Survival 88.2% at 22 years (15) Freedom from reoperation 41.2% at 11 years (7) P.O. Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Supravalvular Aortic Stenosis Apico-Des. Aorta-Conduit Porcelain aorta Repeatedly pre-cardiac surgery Following Konno-Procedure Transthoracic Approach to Implant Apico-Aortic Conduits Cooley et al. Ann Thorac Surg 2000;69:1511-14 Early mortality 6% to 11% 5-years survival 70% Problems Conduit valve failure Conduit thrombosis High reoperation rate Congenital Valvular Aortic Stenosis Left Ventricular Hypertrophy 15-year-old boy died after open aortic comissurotomy Konno-Rastan Aortoventriculoplasty (11Pts, 16Ops) Mean age7.9yrs. (3 38) Early mortality 0% 20-years survival (8)72.7% Complications 5-years Re-Stenosis (2) 18.1% 15-years Re-Stenosis (6) 54.5% High reoperation rate inclu. re-re-op. (1 re-re-re-op) Re-op: Apico-Aortic Conduits 3 (died 1) Re-op: Transapical AVR 2 (died 1) Re-op: VAD-HTX1 Re-op: TAH1 (survival 1yr.) Konno-Rastan Aortoventriculoplasty Transcatheter AVR (Hybrid/Intenvention) CE Mark Approval Main Inclusion Criteria Logistic EuroSCORE of 20% &/or STS Risk Calculator score of 10 Patient has senile degenerative aortic valve stenosis with a mean gradient 40 mmHg and/or jet velocity greater than 4.0 m/s or documented initial aortic valve area (AVA) of 25mm Heavy calcification in front of LM Approach specific contraindication Transcatheter AVR Demographcs (April 08-Feb. 09, n = 78) Euro Score (9) 30% ( early mortality) Age79.1 yrs(39-91 yrs) M/F29/49 NYHA III62 NYHA IV16 AS (n =77)0.71 cm AV (n = 1, AS II, AI III) Pre-Cardiac Surgery(CABG 4, Konno 2)2 Follow-up45-334 d. (100%) Cerebral event2(?) Hospitalization7 d. Clinical Outcomes 30 Days Death8(10.2%)2(2.8%) Arrhythmia2 Stroke2(?) Transvalve3(4.9%) Convention to OHS 2(3.3%) Early death 7 (11.4%) Paravalvular Leck, 2 x TA AVR3 Convention to open heart surgery, MOF2 Postop. Pneumonia2 Myocardiac Insufficiency1 NYHA I NYHA II NYHA III NYHA IV 6 7 45 5 5 PreopPostop N = 68 Conclusions DHZB techniques of aortic valve replacement in small aortic root have been described. Technique is easy and safe.